Typically, most patients present to the doctor because they have symptoms. Careful questioning may reveal that the cause is non-venous despite the presence of a prominent varicose vein. Pain on the first step in the morning suggests a muscular-skeletal-joint disorder. Sharp, shooting, stabbing pains suggest nerve entrapment. Heel pain a calcaneal spur and burning foot pains or numbness diabetes. Easy?

In reality venous symptoms may be more obtuse. Nocturnal itching, tingling and restless legs may represent the typical symptoms of healing after prolonged gravitational stress the previous day. Heaviness, ache and oedema can occur in patients without varicose veins or venous disease. This may be termed occupational oedema or physiological venous insufficiency (drainage insufficiency). Any healthy subject who stands for too long will develop discomfort and pain which is likely to have a multi-factorial aetiology. In obesity with other co-morbidities, the venous nature of any symptoms become less obvious.

Are large ugly varicose veins that do not cause pain considered a cosmetic problem? After prolonged standing of course they will cause symptoms. So the decision to treat on current NHS rationing criteria is easy. In a young lady who is very conscious of her appearance it would be cruel to deny treatment because of the immense psychological stress that these veins may cause to her body image. Is this psychological symptom worthy of NHS rationing criteria? Depending on the degree, a counter argument is that if minor veins are treated, and the patient is pre-occupied with body image, then this may lead on to reshaping and adjustments to other parts.

Darkening of the gaiter region, congestion and swelling of the ankle and the appearance of a corona phlebectatica paraplantaris may be entirely without symptoms. Here the family doctor or relative is often the primary driver to seek treatment. Perhaps correctly this is with the aim to prevent future venous ulceration. In contrast, patients can have terrible gravitational pain after an hour without overt venous signs. A duplex study may reveal gross saphenous incompetence and its treatment result in instantaneous relief.